NÄ PUA NO‘EAU 2011 – 2012 REGISTRATION PLEASE PRINT
STUDENT INFORMATION
Applicant’s name: ______Preferred Name: ______
Gender: Female Male Date of Birth: _____/_____/_____ Hawaiian Ancestry: Yes No
Mailing Address: ______
School Attending: ______Current Grade: ______
Students Phone: (____)______Students E-Mail: ______Social Networks: ______
Student lives with: ______Other Address: ______
Head of Household/ Relation to Phone
Guardian’s Name: ______Applicant: ______(Res): (_____)______
Phone Phone
(Bus) (_____)______Other: (_____)______E-mail: ______
Other/ Relation to Phone
Guardian’s Name: ______Applicant: ______(Res): (_____)______
Phone Phone
(Bus) (_____)______Other: (_____)______E-mail: ______
In case of an emergency, list three people who you would like us to contact if we are unable to contact you.
Contact Name Relation to Child Home Phone Work Phone Other Phones
1)______
2)______
ETHNICITY OF STUDENT: (Please check all that apply. Information collected is for research purposes.)
q American/Native Indian q African American/Black q Caucasian/White q Chinese q Filipino q Native Hawaiian *
q Hispanic/Latino q Japanese q Korean q Pacific Islander q Portuguese q Puerto Rican q Other ______
* If Hawaiian please check all that apply:
q I have personal copies of my child’s birth certificates stating specifically that they are of Hawaiian ancestry
q I have personal records of my child’s ancestry in Hawai‘i prior to year 1778
q My child is in the Office of Hawaiian Affairs’ Hawaiian registry
q My child is in the Kamehameha Schools’ Hawaiian registry
q Besides Nä Pua No‘eau, my child is currently receive services and/or in programs specifically set up for Native Hawaiian children
(i.e. Queen Lili‘uokalani Children’s Center, Alu Like, etc.)
q Other forms of verifying Hawaiian ancestry (please specify) ______
ACCIDENT, MEDICAL, FIELD TRIP AND MEDIA RELEASE
I/We, ______, parents or guardian of ______, release all officers,
directors, staff members, kumu, kökua and all other sponsoring agencies and/or organizations of any claim for damages, liability, injury, expense, or loss on account of negligence or other wrong doing that may occur while my/our child is attending Nä Pua No‘eau activities held during June 1, 2011 to May 31, 2012. I/we also agree to indemnify and hold harmless those persons of the above stated organizations on any claim arising out of the Nä Pua No‘eau activities under this agreement. In case of accident or need for medical attention, I/we give permission to the Nä Pua No‘eau director or other staff members to take my/our child to a doctor, dentist and/or emergency medical facility. I/we give permission for my/our child to participate in field trip(s) associated with the program. I/we give permission to Nä Pua No‘eau to transport my/our child in a NON-school approved vehicle as they deem necessary and therefore I/we waive also the State’s liability.
I/we also hereby give permission to the Nä Pua No‘eau to film, tape, or otherwise record my/our child’s name, voice, and/or person. I/we understand that these recordings of my/our child may include news releases to include photographs about Nä Pua No‘eau and other media releases to publicize Nä Pua No‘eau, and open-circuit (broadcast), closed-circuit, and/or cable television transmission within or outside of the State of Hawai‘i in perpetuity. I/we also understand that there will be no financial or other remuneration for recording my/our child, either for initial or subsequent transmission or playback. Data from applications will be used for program planning and research purposes only.
FATHER’S OR LEGAL GUARDIAN’S SIGNATURE DATE MOTHER’S OR LEGAL GUARDIAN’S SIGNATURE DATE
Student 2011-12 Registration Rev 3/2011
Nä Pua No‘eau
Center for Gifted and Talented Native Hawaiian Children
200 W. KÄWILI STREET
HILO, HAWAI‘I 96720-4091
PHONE: (808) 974-7678
FAX: (808) 974-7681
An Equal Opportunity / Affirmative Action Institution
MEDICAL INFORMATION
Please fill out below and attach a copy of your medical card with the subscriber name and membership number of your medical insurance.
Subscriber Name: ______Medical Plan: ______
Membership Plan # ______Family Doctor: ______Phone Number: ______
Yes In case of accident or need of medical attention, I give permission to the Nä Pua No‘eau director or other staff members No to take my/our child to a doctor, dentist and/or emergency medical facility if unable to contact anyone listed.
MEDICATION
List all medication your child is presently taking;
Medicine/Drug Name Illness
______for ______
______for ______
______for ______
NOTE: Nä Pua No‘eau will not dispense any medication to your child, including aspirins and medicine. Your child must bring his/her
own medication in clearly labeled containers. During the program, be sure your child has enough medication to last during the session.
ALLERGIES
List any allergies or dietary restriction your child may have: ______
______
______
IMMUNIZATION INFORMATION
In what year did your child last receive a: Tetanus Shot? ______Vaccinations? ______Tuberculosis Test? ______
RESTRICTIONS/LIMITATIONS
Please list any challenges your child has which may prevent him/her from participating in activities: ______
______
______
List any activity in which your child cannot participate or you do not want your child to participate: ______
______
______
Are there any religious restrictions on what your child can do or be done in an emergency or other health situations?
Yes No If yes, please explain ______
______
______
Indicate your preference concerning your child’s swimming ability: My child may NOT swim. Nä Pua No‘eau staff may limit my child’s participation based on my child’s ability to swim and staff judgment of swimming conditions.
RESEARCH
Are you eligible for “Free and Reduced Price School Meals” Program? Yes. No.
Do you live on (DHHL) Department of Hawaiian Home Lands? Yes. No.
Mahalo, to the Office of Hawaiian Affairs for funding Nä Pua No‘eau Programs.
Return this registration to a Nä Pua No‘eau office:
Nä Pua No‘eau
Center for Gifted and Talented Native Hawaiian Children
200 W. KÄWILI STREET
HILO, HAWAI‘I 96720-4091
PHONE: (808) 974-7678
FAX: (808) 974-7681
An Equal Opportunity / Affirmative Action Institution